Lymph Node Metastases

Patients with clinically positive lymph nodes should have a complete nodal dissection. The diagnosis is generally confirmed by fine needle aspiration. Overall 5 year survival of patients who have positive nodes resected is between 30 and 50%. Without resection of nodal metastasis patients certainly die; therefore, lymph node resection for positive nodes is a potentially curative procedure. Edema of the extremity and wound infection are the most common complications. Occasionally patients present with nodal disease and no identifiable primary lesion, also known as unknown primary. These patients should have complete nodal dissection. The prognosis for patients with unknown primary is similar to that of other patients with nodal disease.

The management of patients with clinically negative nodes is controversial. In the past, surgeons have either waited until lymph nodes become clinically positive or performed an elective lymph node dissection (ELND) early. Older literature suggests that patients with thin (less than 1 mm thick) or thick (greater than 4 mm thick) melanomas, who do not have clinically positive nodes, are the least likely to benefit from elective lymph node dissections. The patients with intermediate thickness melanomas had been considered the group most likely to benefit. However, three randomized prospective trials failed to show a survival benefit to ELND when compared to observation and subsequent resection of palpable nodes. A subgroup of patients with 1-2 mm thick lesions were found in one study to have a survival improvement with elective lymph node dissection but the role of ELND is not established.

Melanoma appears to metastasize over an identifiable route. Cutaneous areas usually drain first to a limited set of lymph nodes known as sentinel lymph nodes. If the sentinel lymph nodes do not have melanoma, then the other lymph nodes are unlikely to be positive. Radionuclide or blue dye can be injected into the area of the primary melanoma, and the marker traced to the first or sentinel lymph nodes. The sentinel lymph nodes can then be biopsied without removing the entire drainage basin. These lymph node biopsies are now routinely performed for melanomas greater than 1 mm thick. Sentinel lymph node biopsies are relatively small procedures with minimal morbidity and small number of risks.

Sentinel lymph node biopsy provides prognostic information that is of some direct value to patients and that affects decisions about adjuvant therapy. In addition, completion lymph node dissection is generally recommended when the sentinel node biopsy is positive, though the long-term survival advantage of that surgery is not defined. Adjuvant therapy with interferon alfa-2b originally demonstrated benefit to patients with bulky nodal disease, and sentinel lymph node biopsies were designed to identify a group of patients with nodal disease (stage III) so that they could receive adjuvant therapy. The benefit of interferon alfa-2b has not been confirmed with follow up studies. Identification of patients who have stage III disease also permits their enrollment in some trials of experimental therapy.

Distant Metastasis

How To Prevent Skin Cancer

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